Download ICD-10 - Anderson Health Information Systems

ICD-10
ORIENTATION IN
POST ACUTE CARE
Rhonda Anderson, RHIA
Anderson Health Information
Systems, Inc.
General Coding Guidelines
• Locating a code in the ICD-10-CM
• Level of detail coding
• Code/codes from A00.0 through Z99.8
• Signs and symptoms are acceptable for
reporting purposes when a related diagnosis
has not been established
• Signs and symptoms that are associated
routinely with a disease process should not
be assigned as additional codes
2
General Coding Guidelines -2
• Acute and Chronic Conditions
• If the same condition is described as both acute
and chronic, and separate subentries exist, code
both and sequence the acute code 1st
• Combination Code
• Is a single code used to classify two diagnoses,
or
• A diagnosis with an associated complication or
manifestation
3
General Coding Guidelines -3
• Late Effects (Sequela)
• Residual effect (condition produced) after the
acute phase of an illness/injury has terminated
• There is no time limit on when a sequela code
can be used
• Coding generally requires two codes
• Condition/nature of the late effect is sequenced
1st; the sequela code is sequenced 2nd
• Exception is when the sequela code is part of the
4th, 5th or 6th character of a code
4
General Coding Guidelines -4
• Late Effects (Sequela)
• The code for the acute phase of an illness or
injury that led to the sequela is never used with a
code for the late effect
5
General Coding Guidelines -5
• BMI & Pressure Ulcer Stages Documentation
• Assignment may be based on medical record
documentation from clinicians who are not the
patient’s providers
• Dietitian often documents the BMI and nurse often
documents the pressure ulcer stages
• The associated diagnosis must be documented by
the patient’s provider
• BMI codes should only be reported as secondary
diagnoses
6
Complications Of Care
• Code assignment is based on the provider’s
documentation
• Not all conditions that occur during or
following surgery are classified as
complications
• When admission is for treatment of a
complication, the complication code is
sequenced as the principal diagnosis
7
Complications of Care -2
• Must be a cause-and-effect relationship
between the care provided, the condition and
an indication in the documentation that it is
a complication
8
OSHPD / Principal Diagnosis
Definition
• Uniform Hospital Discharge Data Set
(UHDDS)/Principal diagnosis is defined as
that condition established, after study, to be
the chief cause of the admission of the
patient to the facility for care
• Condition must be identified in the H&P or
documented in the current inpatient medical
record
9
Acute Hospital – Principal Dx
• What that means to a SNF
• Acute hospital diagnosis
• Late effects of the acute diagnosis
• Reason for the admission to Acute and the SNF
(bundled payments) – one facility gets paid and
the other is paid by that facility.
10
Principal Diagnosis
• Two or more interrelated conditions with
each potentially meeting the definition
• Diseases in the same ICD-10-CM chapter or
manifestations characteristically associated with
a certain disease, either condition may be
sequenced first, unless the circumstances of the
admission, the therapy provided, or the code
book indicate otherwise
11
Principal Diagnosis -2
• Two or more interrelated conditions that
equally meet the definition
• When two or more diagnoses equally meet the
criteria for principal diagnosis as determined by
the circumstances of admission, diagnostic
workup and/or therapy provided, and the code
book does NOT provide sequencing direction,
any one of the diagnoses may be sequenced first
12
Other Diagnoses
• Two or more comparative or contrasting
conditions
• When two or more diagnoses are documented as
“either/or”, they are coded as if the diagnoses
were confirmed and the diagnoses are sequenced
according to the circumstances of the admission.
• Either diagnosis may be sequenced first.
• When a symptom is followed by
contrasting/comparative diagnoses, the symptom
code is sequenced first.
13
Other Diagnoses -2
• Two or more comparative or contrasting
conditions (cont.)
• All the contrasting/comparative diagnoses should
be coded as additional diagnoses.
• These should never be principal diagnoses
14
Signs, Symptoms, Ill-defined
Conditions
• Codes for symptoms, signs, and ill-defined
conditions – are NOT to be used as a
principal diagnosis when a definitive
diagnosis has been established.
• THIS APPLIES TO SNF, ACUTE and other
health-care locations
15
Uncertain Diagnoses
• If the diagnosis documented at the time of
discharge is qualified as “probable”,
“suspected”, “likely”, “questionable”,
“possible”, or “still to be ruled out”, or other
similar terms indicating uncertainty, code
the condition as if it existed/established
• Applicable only to inpatient admissions to
short-term, acute, long-term care &
psychiatric hospitals
16
Sequencing Of Codes
• Determined by the reason for
admission/encounter, with the highest acuity
diagnoses sequenced 1st
17
Specificity Of Coding
• With added laterality, need greater
documentation from your MD’s
• Hypertensive Retinopathy H35.03_
• H35.031 right eye
• H35.032 left eye
• H35.033 bilateral
• H35.039 unspecified (this would be a ?? for
billing most likely!!)
• *code also any associated hypertension (I10)
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Chapter 1 – Infectious & Parasitic
Diseases A00-B99
• B95 Streptococcus, Staphylococcus, and
Enterococcus as the cause of diseases
classified elsewhere
• B96 Other bacterial agents as the cause of
diseases classified elsewhere
• B97 Viral agents as the cause of diseases
classified elsewhere
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Sepsis
• UROsepsis – The term urosepsis is a
nonspecific term. It is not to be considered
synonymous with sepsis. It has no default
code in the Alpha index.
• QUERY THE DOCTOR!!!
• Sepsis with organ dysfunction
• follow guidelines for severe sepsis
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Chapter 1 – Infectious & Parasitic
Diseases A00-B99 -2
• Sepsis (ICD-9 = 995.91)
• Unspecified organism, A41.9, if type of infection
is not specified
• Severe sepsis R65.2 should not be assigned
unless severe sepsis or acute organ dysfunction
is documented
21
Sepsis – Severe
• Requires two codes
• First code for underlying systemic infection
followed by a code from subcategory R65.2,
Severe Sepsis
• Casual organism should be documented; if
not – assign A41.9 Sepsis, unspecified
organism
• Where do we look for this information?
22
Sepsis Example
• This long-term multiple sclerosis patient
was admitted for continuing long-term
antibiotic therapy for a urinary tract
infection due to E. coli.
• What do we code?
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Sepsis Answers
• N39.0 Infection, urinary tract
• B96.20 Infection, E. coli
• Z79.2 Long-term use of antibiotics
• G35 Sclerosis, multiple
• The long-term use code is assigned for use of the
antibiotics. Instructional notes under N39.0
indicate to use an additional code (B95-B97), to
identify infectious agent
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Chapter 1 – Infectious & Parasitic
Diseases A00-B99 -3
• When a patient is diagnosed with an
infection that is d/t MRSA, and that
infection has a combination code that
includes the causal organism, assign the
appropriate combo code:
• A41.02 Sepsis d/t MRSA, or
• J15.212 Pneumonia d/t MRSA
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Chapter 1 -4
• When a patient is diagnosed with an
infection that is d/t MRSA, and that
infection has a combination code that
includes the causal organism, assign the
appropriate combo code:
• B95.62 MRSA as the cause of conditions
classified elsewhere
• Only used when the infection does not have a combo
code that includes the causal organism
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Chapter 1 -5
• MRSA/MSSA Colonization:
• A positive MRSA colonization test may be
documented by the MD as “MRSA screen
positive” or “MRSA nasal swab positive”
• Assign Z22.322, carrier or suspected carrier of
MRSA
• Colonization is not indicative of a disease
process
• If patient is documented as having both MRSA
colonization and infection, code both
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Chapter 1 -6
• HIV infections
• Code only confirmed cases of HIV infection,
• MD’s diagnostic statement is sufficient
• Admit for HIV-related condition, principal
diagnosis should be B20, followed by code for
HIV-related condition
• Z21 is assigned when the patient w/o any
documentation of symptoms is listed as “HIV
positive” or “known HIV”
28
Chapter 2 – Neoplasms C00-D49
• Increase in subcategories from 9, to 21 in
ICD-10-CM
• Greater specificity by site and laterality
• Need to know: upper, lower, overlapping
sites, left, right, etc.
• If cancer treatment is done, then a history
code is assigned - Z85.
29
Primary Malignancy Previously
Excised
• When there is no further treatment directed
to a primary site and no evidence of any
primary malignancy, the following is coded:
• Z85. Personal history of malignant neoplasm
(meant for coding of primary sites only)
• Any mention of metastasis to another site is
coded as a malignant secondary neoplasm to
that site.
30
Chapter 3 – Blood and Blood
forming Organs, Certain Immune
Disorders D50-D89
• D50-D53 Nutritional anemias
• D55-D59 Hemolytic anemias
• D60-D64 Aplastic and other anemias
• D65-D69 Coagulation defects
• D70-D77 Other disorders of the blood
• D78 Postprocedural complications spleen
• D80-D89 Disorders involving immunity
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Chapter 4 – Endocrine, Nutritional,
Metabolic E00-E89
• Diabetes Mellitus
• Combination codes
• Includes the type of diabetes, the body system
affected, and the complications affecting that
body system
• Many codes within a particular category as are
necessary to describe all of the complications of
the disease may be used
• Sequenced based on the reason for a particular
encounter
32
Chapter 4 – Endocrine, Nutritional,
Metabolic E00-E89 -2
• E08 Diabetes d/t underlying condition
• E09 Drug or chemical induced diabetes
• Secondary diabetes is always caused by another
condition or event
• E10 Type I Diabetes Mellitus
• E11 Type II Diabetes Mellitus
• E13 Other specified Diabetes Mellitus
• Z79.4 Long-term use of insulin
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Type Of Diabetes
• If the type of diabetes is not documented in
the record, the default is E11., Type 2
diabetes
• If the type is not indicated, but the patient
uses insulin, code E11. Type 2 diabetes +
Z79.4 long-term use of insulin
• Need to know:
• type of DM
• body system affected + complications
34
Diabetes Example
• Resident admitted to SNF following foot
amputation d/t diabetic PVD. PT and OT
ordered with plan for the resident to return
home. Staff to change dressings and report
any suture site breakdown to MD. Other
diagnoses include gastroparesis d/t Type 2
diabetes (receiving insulin), mitral valve
regurgitation with aortic stenosis, inguinal
hernia, generalized DJD and COPD.
35
Diabetic Answer
• Z47.81 Aftercare, following surg, amp
• E11.51 Diabetes, type 2, w/peri angiopath
• E11.43 Diabetes, type 2, w/gastroparesis
• I08.0 Regurgitation, mitral, w/aortic valve
• K40.90 Hernia, inguinal
• M15.9 Disease, joint, degenerative
• J44.9 Disease, pulmonary, chronic obstruc
• Z79.4 Long-term use insulin
• Z89.439 Acquired absence of unspec foot
36
Rationale
• Both PVD and gastroparesis are d/t type 2
diabetes. Codes assigned for both
conditions.
• Z47.81 has a “use add’l code” note to
identify the limb and level of amp Z89.439
Documentation doesn’t specify which foot
was amp, so 6th digit of 9 is assigned.
• Pt uses insulin, so Z79.4 is assigned.
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Dehydration
• E86.0 Dehydration
• Need to know if this is a current condition,
otherwise do NOT code
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Chapters 5 – Mental & Behavior
Disorders F01-F99
• F01. Vascular Dementia
• F02. Dementia in other diseases classified
elsewhere
• F03. Unspecified Dementia
• *All of above are coded:
• with behavioral disturbance, or
• without behavioral disturbance
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Key to Psychoactive Drug Use
Documentation
• Make sure each psychoactive drug includes
diagnosis for use
• Behavioral disturbance??? Justification for
psychotropic meds??? Documentation of
aggressive, combative or violent?
• Use of antipsychotic meds need specific
medical diagnosis to justify use:
• Schizophrenia - F20., Bipolar – F31., Psychosis
(delusions or hallucinations) – F29.
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Bipolar Disorder – F31
• Expanded subcategories:
• F31.1 Bipolar, current episode manic
• F31.3 Bipolar, current episode depressed
• F31.6 Bipolar, current episode mixed
• F31.7 Bipolar, currently in remission
• Need to know for above:
• with or without psychotic features
• mild, moderate, severe
41
Substance Abuse Codes
• Expanded to include intoxication and
specific mood states that are a result of a
variety of substances:
• Anxiety, sleep disorder, psychosis
• By drug type:
• Alcohol, Opioid, Cannabis, Sedative/hypnotic,
Cocaine, other stimulant, hallucinogen, nicotine,
inhalant)
• Example: F10.180 Alcohol abuse with alcoholinduced anxiety disorder
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